Charlie Krumholz, Chief Perfusionist at the UVM Medical Center discusses how the hospital has lowered the percentage of patients who require a blood transfusion during cardiac surgery, and what it means for patients and providers.
Listen to the interview at the link below or read the transcript that follows.
UVM Medical Center: Undergoing cardiac surgery may cause some patients to lose blood in the operating room, requiring a transfusion. The percentage of cardiac surgery patients who need to receive blood during surgery is a hospital’s transfusion rate. Since 2014 The University of Vermont Medial Center has reduced its transfusion rate to one of the lowest rates in the country.
Today we’re talking with Charlie Krumholz, Chief Perfusionist at the UVM Medical Center, about how the hospital has lowered the percentage of patients who require a blood transfusion during cardiac surgery, and about what it means for patients and providers. Thanks for joining us today, Charlie.
Charlie Krumholz: You’re welcome.
UVM Medical Center: Let’s start with the basics. Your title might sound a little bit unfamiliar to many of our listeners – can you tell me what “Chief Perfusionist” does exactly?
Charlie Krumholz: Perfusion is a very small profession, there are three perfusionists in Vermont. I started in 1989 and we perform about 480 elective open heart procedures requiring cardiopulmonary bypass.
UVM Medical Center: To really break it down, you work with blood.
Charlie Krumholz: We work with blood, yes. We pump it, we collect it and process it, give it to the patients, correct.
UVM Medical Center: And the term “transfusion rate” means the percentage of patients who require a blood transfusion during surgery?
Charlie Krumholz: That’s correct. Ideally we would like to keep that transfusion rate as low as possible, but it depends on the clinical situation. Sometimes patients have lost a lot of blood and they do need a transfusion; in that instance it’s lifesaving. Sometimes they need packed cells, sometimes they need platelets and plasma for bleeding issues post-surgery. We try to maintain their hematocrit as high as possible.
UVM Medical Center: Do transfusion rates vary from state to state or from hospital to hospital?
Charlie Krumholz: They do tremendously. That’s an issue that I think we can work on in medicine. That is, in surgery the rate of transfusion in this country varies between about 9% and close to 90%. There’s a very wide range and some institutions are at the low end and some are still at the high end. It’s a very important thing to work on because blood is expensive and it affects outcomes.
UVM Medical Center: See, when I first started talking to you about this I thought that the transfusion rate meant the percentage of a patient’s blood that you had to switch out during surgery.
Charlie Krumholz: No, no.
UVM Medical Center: I was like, “Some hospitals do 90%? That’s terrifying.”
Charlie Krumholz: We have actually done that on some patients, yes. There are some pretty difficult cases sometimes.
UVM Medical Center: Could you talk about where UVM Medical Center fits in the variance around the country?
Charlie Krumholz: In 2012 we were transfusing about 70% of our patients, so quite a high rate, but we’ve been working on that. Bruce Leavitt, one of our cardiac surgeons, developed a blood conservation committee and got nurses and perfusionists and surgeons and the urology doc, Richard Solomon, and some other residents involved. Anesthesia is a critical component of that. Our staff is great at working on this and we’ve made a lot of changes that have… By 2015 we had dropped to about 15% to 20% transfusion and we’re still in that area, pretty close to that, by changing a lot of small steps.
UVM Medical Center: What kind of steps does it actually take to reduce transfusion rates – tools, procedures, attitudes?
Charlie Krumholz: Some of it is attitudes and how we look at these patients. Anesthesia has changed the amount of crystalloid fluid they give the patients pre-bypass, when they’re in the operating room. They’ve also changed the types of drugs they’re using to put patients to sleep.
We’re using much less fentanyl and narcotics, and using Ketamine and Propofol and inhalational anesthetics and IV Tylenol and some other drugs that don’t require as much fluid, the patients don’t get dilated as much so they have adequate blood pressure even with less fluid. This makes a big difference for us because their hematocrits don’t drop so they carry more oxygen in their blood, which is good for kidneys and also reduces acute kidney infection (AKI) and also infection.
UVM Medical Center: I think you’re getting at why a hospital would want to reduce its transfusion rate. Do patients do better?
Charlie Krumholz: Yes. Our AKI rate was 7% in 2012 and by 2015 it had dropped to 2.8%, which is extremely low. This is for severe acute kidney injury. When you get a unit of somebody else’s blood it affects your immune system – your immune system tries to fight that off because it’s a foreign invader.
UVM Medical Center: I think you also mentioned that it impacts infection rates.
Charlie Krumholz: Yes, absolutely. There’s a direct correlation. It’s never been proven that blood increases infections that I know of but there’s a direct correlation with infection. The more units of blood you get, there are many papers in the literature that show that you have a higher infection rate. It’s really important for these patients who often are diabetic and have longstanding disease, cardiac disease and other comorbidities. We want to keep that infection rate as low as possible because they can be very debilitating infections, and expensive; they have to stay in the hospital longer and it’s quite expensive for the therapy.
UVM Medical Center: If you’re just tuning in to Health Source, our guest today is Charlie Krumholz, Chief Perfusionist at the UVM Medical Center. We’re talking about the hospital’s successful effort in the past few years to reduce the percentage of patients who require a blood transfusion when undergoing cardiac surgery. You mentioned that it’s expensive if somebody stays in the hospital longer as a result of an infection, which we’re trying to reduce. Is it also more expensive for the hospital in that case?
Charlie Krumholz: It is. Yes, absolutely. The blood is very expensive but also staying in the hospital and the staff to keep those patients well cared for is very expensive. Minimizing hospital length of stay is also correlated with lower infection rates. We want to get them up and mobile because their pneumonia rate will then be much lower.
By anesthesia decreasing the amount of anesthetic narcotics they use, they also can extubate patients quicker, get the tube out of their throat and get them up and moving. That is good to decrease pneumonia and to help keep people getting better quickly. That helps decrease cost and also involves having the bed available for other patients so we can get them in and out in four or five days in many cases, and that makes a bed available for another patient.
UVM Medical Center: If we are purchasing fewer blood products as a result of lowering our transfusion rate, does that save the hospital money?
Charlie Krumholz: Hundreds of thousands of dollars, yes.
UVM Medical Center: Good to know.
Charlie Krumholz: A five pack of platelets is about $1,000. A unit of packed cells, red blood cells, is about $270. There’s processing fees and cost for storage and all the testing that has to be done to ensure that it doesn’t have any bacteria or problems with that blood. It has to be cross-matched and typed and crossed.
UVM Medical Center: How do you decide what kind of blood product somebody needs? I’m sure that’s a complicated question.
Charlie Krumholz: It is, but there are lab tests that we do to show whether they need plasma, platelets, red blood cells. We send lab samples down and they give us the results that show us, direct us to what type of therapy we should be giving. Often it’s a combination of those three products, sometimes we use another product called cryoprecipitate. We work with the hematologist and the blood bank and the lab to make sure we’re giving the appropriate therapy.
UVM Medical Center: With the changes that we’ve made to processes and materials that you use to reduce transfusion rates, would a patient undergoing cardiac surgery here today experience anything differently than they would have in 2012, say?
Charlie Krumholz: I think it’s made a tremendous difference in our patients’ outcomes and they also feel better. Even if you’re young and your hematocrit dropped significantly, say 20% or 30%, you would feel very weak and lethargic. Imagine if you were in your eighties and having open heart surgery, you also feel very weak and it’s difficult for you to recover as quickly because your hematocrit is low. It’s critical to keep those hematocrits high. Patients can move about better and feel better and be stronger quicker, and get back to their home.
UVM Medical Center: And hematocrit is?
Charlie Krumholz: Hematocrit is the level of red blood cells in the patient’s body. An average for a male is about 40% hematocrit, red blood cells. The female’s slightly lower, about 36%. Often times some of these patients are anemic because of various processes going on. Sometimes they have bleeding ulcers or other types of problems that may make them anemic, or just low iron. It’s a very common problem, especially for women. Elderly women are smaller of stature in the first place so that makes a difference in terms of the hemodilution because we’ve also tried to decrease the prime of our pump so they don’t get hemodiluted so much, which keeps hematocrits higher. That makes a big difference as well.
UVM Medical Center: And hemodilution is?
Charlie Krumholz: Hemodilution is the amount of fluids you get which decreases the relative mass of red cells in proportion to the whole body volume. We have some new techniques as well that we’re using. One is called reverse autologous priming, or RAP. What that does is we drain some of the crystalloid out of the pump and replace it with a patient’s blood right before we go on bypass. That helps keep hematocrits higher. It’s one more technique in a series of steps that we use.
We also use cell savers at the end of the case to process all the blood that’s left in the pump. We try to get as much of the platelets, plasma and red cells back into the patient, and then we process the rest in the cell saver, which is a portable centrifuge. We spin down the blood, we wash it and we give it back to the patients, very quickly, in a matter of 15, 20 minutes.
UVM Medical Center: Help me understand this if I’m wrong but it sounds like you’re saying that we can start by transfusing some of the patient’s own blood into them when they start –
Charlie Krumholz: Yes, absolutely. Yeah.
UVM Medical Center: Cool.
Charlie Krumholz: That is a very good thing because it doesn’t have the negative effects of blood coming from other people. We’ve been working on this for many years, it’s getting better and better. At least five years that we’ve really been doing significant progress.
UVM Medical Center: Are other hospitals trying to reduce their transfusion rates as well across the country, around the world it sounds like?
Charlie Krumholz: Yeah, absolutely, absolutely. Yes. I’ve been speaking with people at the Mayo Clinic in Rochester, which is very well known, and the Cleveland Clinic, Emory University in Atlanta and a number of my other colleagues across the country and in Canada as well. And Europeans now, I’ve been chatting with them about what their techniques are and how can we make this better. There’s a lot to learn and we all can do a little bit better. There are some new technologies, there are smaller primes that we can use. These things make a big difference. Even very small steps when put together in the big picture help a lot.
UVM Medical Center: What should a patient know going into cardiac surgery here at the UVM Medical Center, or really anywhere?
Charlie Krumholz: I think it’s important that they know their team is really focused on decreasing blood use and that they’re dedicated to trying not to transfuse those patients if they don’t need it. Obviously in a clinical situation that warrants the blood we will give it – there’s no question sometimes based on laboratory values that they need these products. I think it’s an awareness by all the members of the team in the hospital and the dedication to improving the process.
UVM Medical Center: Our guest today on Health Source has been Charlie Krumholz, Chief Perfusionist at the UVM Medical Center. Thanks very much for joining us.
Charlie Krumholz: Thank you very much.